Adolescent Questionnaire

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Adolescent Questionnaire

ADULT QUESTIONNAIRE

DATE:

FATHER OR MOTHER CONTACT PHONE:

EMAIL:

CHILD’S NAME:

FATHERS NAME:

MOTHERS NAME:

Please then answer the following questions

AGE

CLASS

SEX

DOES YOUR CHILD HAVE INCURANCE?YESNO

DOES YOUR CHILD KNOW YOU'RE COMMUNICATING WITH US?

DOES HE/SHE HAVE SIBLINGS?

HOW MΑΝΥ:

HOW OLD ARE THEY:

OCCUPATION OF FATHER:

OCCUPATION OF MOTHER:

WHERE YOU INFORMED ABOUT ANASA?

WHAT PROBLEM IS THE CHILD FACING?

WHEN DID IT START?

WEIGHT:

HEIGHT:

HOW DOES HE/SHE LOSE WEIGHT (BY DIETING, EXERCISING OR OTHER WAYS)?

DOES HE/SHE USE PILLS?

DOES HE/SHE VOMIT?

DOES HE/SHE HAVE EPISODES OF BINGING?

HOW MANY ΕPISODES DURING THE DAY?:

PLEASE GIVE AN EXAMPLE:

HAS BEEN OBSERVED BY A PSYCHOLOGIST/ PSYCHIATRIST IN THE PAST:

ACCEPTED (TO BE COMPLETED BY THE RESPIRATORY SPECIALIST):

AUTHORITY- COMMUNICATION (TO BE COMPLETED BY ANASA'S SPECIALIST):

I confirm the accuracy and correctness of the above information which I myself/herself filled in as the parent of my minor child, and I sign.

Name and Signature

(Note: This completed form will be given to you for signature when you visit KI ANASA on your 1st appointment)

I have read the Notice on the collection and processing of personal data and by submitting my and my minor child's details, I declare my consent.

Subsequently, the clinical team of KI ANASA will receive the completed questionnaire, evaluate it and the Secretariat of KI ANASA will call you to schedule the 1st appointment with a specialist of our Center.

Thank you very much and we will contact you soon!